Microblading and shading Consent Form
Helium salon
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Do any of the following pertain to you?
*
Pregnant or nursing
Diabetic
Skin diseases
Botox in the last 2 months
Accutane in the last 6 months
Blood thinners
Pain intolerant
Epileptic
Autoimmune disease
Cancer, Or had Chemo therapy or radiation
HIV
Chemical Peels in the last month
Heart conditions
Hepatitis
Keloid scars
Alopecia
None of the above
If you selected anything from above, please explain:
If yes, please identify the condition.
Would you consider your skin:
*
Very oily
oily
dry
combination
Do you have any previous permanent make up and or microblading on your eyebrows?
*
yes
no
Do you have a preferred artist?
*
first available
Renata
Sierra
Kenley
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
In order to book a consultation we do require a $50 deposit. Should you book a treatment with one of our artist the $50 will be applied to your deposit. However if you choose to not book an appointment the cost of the consultation is $50 and non refundable.
Please upload a picture of your eyebrows, with no make up on.
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